Reassignment surgery, now more commonly called gender-affirming surgery, is a set of surgical procedures that alter a person’s body to better match their gender identity. There is no single operation. The term covers a wide range of procedures, from chest surgery and facial reshaping to the construction of new genitalia, and most people pursue only the specific surgeries that address their needs.
Why the Terminology Has Changed
You’ll still see “sex reassignment surgery” or “gender reassignment surgery” in older medical literature and search results, but most major medical centers now use “gender-affirming surgery.” The shift reflects a broader understanding that these procedures don’t change someone’s gender so much as bring the body into alignment with how the person already identifies. The older clinical term “transsexual” has also largely fallen out of professional use, though some individuals still connect with it.
Types of Procedures
Gender-affirming surgeries generally fall into three categories: top surgery (chest), bottom surgery (genitals), and facial procedures. Not everyone pursues all three. Some people have one procedure; others have several over a period of years.
Top Surgery
For transmasculine patients, top surgery means chest masculinization, which removes breast tissue and reshapes the chest wall. The most common technique is the double incision mastectomy, which works well for people with moderate to large amounts of breast tissue. For those with very small breasts and minimal excess skin, a keyhole (periareolar) approach uses a small incision along the lower edge of the areola to extract tissue with less visible scarring. This option is used less often because it isn’t effective for larger or sagging breasts.
For transfeminine patients, top surgery means breast augmentation using implants, similar to cosmetic augmentation performed for cisgender women. Many transfeminine individuals first try hormone therapy, which can produce some breast development on its own, before deciding whether augmentation is necessary.
Bottom Surgery for Transfeminine Patients
The two main options are vaginoplasty and vulvoplasty. Vaginoplasty creates both the external vulva and an internal vaginal canal. The most established technique is penile inversion, where penile skin is repurposed and inverted to line the new canal. A newer approach, robotic peritoneal flap vaginoplasty, uses tissue from the peritoneum (the membrane lining the abdomen) to construct the canal, which can be helpful when there isn’t enough donor skin available.
Vulvoplasty creates the external appearance of a vulva, including labia, without constructing an internal canal. It’s a good fit for people who don’t want or don’t need vaginal depth, and it involves a shorter recovery. Some people start with a vulvoplasty and later pursue a full vaginoplasty if their goals change.
Bottom Surgery for Transmasculine Patients
The two primary options are phalloplasty and metoidioplasty, and the choice between them is highly personal.
Phalloplasty constructs a full-sized penis using tissue grafted from another part of the body, typically the forearm or thigh. It produces genitalia that are closer in size and appearance to a typical penis. Metoidioplasty works with existing anatomy by releasing the clitoris (which has typically grown from testosterone therapy) and repositioning it to function more like a small phallus. It’s a less invasive surgery with a shorter recovery.
A large review comparing the two found no significant difference in overall satisfaction with appearance between patients who chose phalloplasty and those who chose metoidioplasty. Both procedures carry a notable risk of urinary tract complications, including fistulas (abnormal connections between the urethra and skin) and strictures (narrowing of the urethra). These complications are more common in phalloplasty because it requires constructing a longer urethra. On the positive side, between 19% and 54% of urethral fistulas resolve on their own without additional surgery.
Facial Feminization Surgery
Facial feminization surgery (FFS) is a collection of procedures that reshape bone and soft tissue in the face. Common components include forehead contouring, brow lifts, rhinoplasty, cheek augmentation, jaw contouring, and chin reduction. Jaw recontouring involves shaving or cutting the corner of the lower jawbone to create a softer angle. Chin bone can be trimmed, reshaped, or repositioned forward.
A tracheal shave is another common procedure, reducing the prominence of the Adam’s apple. The surgeon makes a small incision in the neck, often placed within natural skin folds to minimize scarring, and shaves away cartilage from the front of the larynx.
Recovery Timeline
Recovery varies significantly by procedure. Top surgery typically involves a few weeks before returning to normal activities. Facial procedures range from a week or two of visible swelling to several weeks of healing for more involved bone work.
Bottom surgery has the longest recovery. After vaginoplasty, patients are usually hospitalized for about three days. A stent stays in place for five days to protect the skin grafts. Most people return to work and daily activities within six to eight weeks, though full recovery can take up to a year. Driving, exercise, heavy lifting, and sexual activity are restricted during the early postoperative period.
The most demanding part of vaginoplasty recovery is dilation: using a medical device to maintain the depth and width of the new vaginal canal. Initially, you dilate several times a day. Over the first year, the frequency gradually decreases. After full healing, most people dilate about once a week, with the exact frequency depending on sexual activity. Skipping dilation can lead to the canal narrowing or closing, so it’s a long-term commitment.
Complications to Be Aware Of
All surgery carries risks like infection and bleeding, but gender-affirming genital procedures have some specific complications worth understanding. For transfeminine vaginoplasty, meatal stenosis (narrowing of the urethral opening) is a particular concern, with rates reported anywhere from 4% to 40% depending on the study. When it occurs, a minor corrective procedure is usually needed.
For transmasculine bottom surgery, urethral strictures and fistulas are the most common complications. These happen more frequently in phalloplasty because the new urethra is longer and more complex. Too much tension on the surgical site during healing can also cause tissue breakdown, which is why physical restrictions during recovery are strict.
Nerve sensation changes are another consideration for all genital procedures. Some patients report reduced sensation, while others report sensitivity that improves over months as nerves heal. Surgeons discuss these trade-offs in detail before the procedure.
Satisfaction and Regret Rates
Research consistently shows high satisfaction with gender-affirming medical care. A study published in JAMA Pediatrics looking at 220 respondents who began care in adolescence found very high satisfaction and low regret with both hormone therapy and puberty blockers. Only 9 of the 220 expressed regret, and just 4 of those stopped all gender-affirming care entirely. These figures align with the broader adult literature, where regret rates across studies tend to fall below 5%.
Cost and Insurance Coverage
The cost of gender-affirming surgery depends heavily on the procedure and your insurance situation. For people with commercial insurance that covers these surgeries, average out-of-pocket costs per procedure are lower than many expect: roughly $2,600 for vaginoplasty, $4,000 for phalloplasty, $2,200 for chest masculinization, and $1,200 for breast augmentation. Facial feminization averages about $1,250 out of pocket with coverage.
Without insurance, the total costs are dramatically higher, often ranging from $10,000 to over $100,000 depending on the combination of procedures.
Insurance coverage has expanded significantly over the past decade. The Affordable Care Act’s nondiscrimination protections were interpreted to prohibit treating a transgender identity as a pre-existing condition. In 2014, Medicare rescinded its longstanding ban on covering gender-affirming surgeries, and a 2016 federal regulation prohibited blanket exclusions of this care in both public and private insurance. As of early 2021, 24 states and territories prohibited blanket transgender coverage exclusions in state-regulated private insurance plans, up from just one before 2010. Coverage still varies widely by employer, plan, and state, so checking with your specific insurer is essential before scheduling any procedure.